2011-08-11T19:05:59-05:00 2010-09-30 DELOITTE TAX LLP 655 WEST BROADWAY SUITE 700 SAN DIEGO CA 921018590 990 2009-10-01 954322584 FACEY MEDICAL FOUNDATION FACE 8183659531 15451 SAN FERNANDO MISSION BLVD No 200 MISSION HILLS CA 913451420 JAMES CORWIN 8183659531 2011-08-11 1 6192326500 2009 2016-02-24 21:20:13Z Bill Gil 15451 SAN FERNANDO MISSION BLVD No 200 MISSION HILLS CA 913451420 189739319 0 X WWW.FACEY.COM X 1991 CA Premier healthcare team providing quality medical service. 10 8 1152 8 13200 -738 4197 13531 172778468 176205101 310245 3040654 60702 18833 173153612 179278119 30765 45016 0 50989613 51899769 0 0 119186077 123115221 170206455 175060006 2947157 4218113 54091539 55984067 27183075 26882731 26908464 29101336 We are a premier healthcare team dedicated to providing quality medical service in a caring and professional atmosphere. Each of us is committed to service, innovation, and quality care while serving the needs of the community. 0 0 158414776 45016 175193116 Direct patient medical care - this includes, but is not limited to, face to face provider appointments, laboratory and x-ray services, physical therapy services, immunizations, provided drugs and medications, procedures in Ophthalmology, OB/GYN, and Gastroenterology. 873873 1011985 Clinical Research: Conducted 26 (14 are active) FDA-regulated studies (161 patients and 1,352 study visits) in various disciplines including Gastroenterology, Endocrinology, Internal Medicine, Oncology, Pediatrics, and Ophthamology. 1053071 Patient Education: 189 Health Education classes, serving 6,981 people, between October 2009 and September 2010. 301195 Flu Clinics: 14,886 vaccinations given during Flu Clinics in the month of October 2009. 301195 160642915 1 1 0 1 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1 134 0 1152 1 1 1 0 0 0 0 0 0 0 0 10 8 1 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 0 1 1 1 1 CA X Margie J Melby 8188375610 15451 San Fernando Mission Blvd 200 Mission Hills CA 913451420 Randall Ewig 1.40 X 20400 0 0 Ronald Kaufman MD 1.00 X 11200 0 0 Gary Leary 8.50 X 64200 0 0 Michael Linn 1.20 X 16852 0 0 J Robert Liset 0.70 X 9400 0 0 Mary Odell 1.00 X 10600 0 0 Larry Scherzer 1.20 X 11500 0 0 Carl Cannata 1.20 X 11500 0 0 Michael Lynch MD 0.90 X 10900 0 0 Peter Richman MD 0.90 X 8900 0 0 Guillermo Gil 40.00 X 409694 0 37323 James Corwin 40.00 X 298850 0 16615 Teresa David 40.00 X 262124 0 25904 Jacki Delanders 40.00 X 154139 0 8039 Margie Melby 40.00 X 130403 0 19515 Stephanie Bamford 40.00 X 104699 0 22623 Patricia Horanberg 40.00 X 122653 0 7914 Prubjeet Khurana 40.00 X 121499 0 5061 Susan Slack 40.00 X 97831 0 23541 David Day 40.00 X 149134 0 13997 Joung Jeffrey Lee 40.00 X 139529 0 4128 Magaly Beilke 40.00 X 134854 0 23297 Mari Zagrzejewski 40.00 X 133757 0 11591 Sybil Tourville 40.00 X 144569 0 22569 2002102 0 163463 25 0 1 0 Facey Medical Group 15451 San Fernando Mission Blvd Su Mission Hills CA 91345 Professional Medical Services 74370175 Marshall Erdman & Associates 350 Interlocken Blvd Bloomfield CO 80021 Construction & Consulting services 4487952 Quest Diagnostics 8401 Fallbrook Ave West Hills CA 91304 Laboratory services 1833378 La Casa Maintenance Inc 9018 Balboa Blvd Suite 281 Northridge CA 91325 Janitorial services 647830 Safety Protective Services 2621 W Olympic Blvd Los Angeles CA 90006 Security services 269713 22 13531 13531 Net Patient services 900099 175193116 175193116 Clinical Research 900099 1011985 1011985 176205101 280854 280854 13217000 4000 10459288 1912 2757712 2088 2759800 2759800 Management Fees 812900 13200 13200 Miscellaneous 900099 5633 5633 18833 179278119 176205101 13200 3046287 45016 45016 1608604 328261 1280343 41882148 37455677 4426471 424105 360489 63616 4641426 3725143 916283 3343486 2831371 512115 657100 657100 199676 199676 10808 10808 6403811 6403811 112587 89721 22866 4095009 1217516 2877493 1972307 1440121 532186 14336718 12879495 1457223 203313 163532 39781 47680 25615 22065 41378 41378 4356706 3470955 885751 2137449 2060707 76742 Medical Fees to FMG 74370175 74370175 0 0 Supplies 12241234 11847990 393244 0 Bad Debt 1927320 1927320 0 0 Misc UBI Expense 1950 0 1950 0 175060006 160642915 14417091 0 12898 13600 12101474 10859926 9345569 8531799 1582805 1722768 2257408 2498773 48787061 30155691 16145406 18631370 12504479 13584331 141500 141500 54091539 55984067 17000269 17381943 3070635 2688884 45728 486356 705177 6361266 6325548 27183075 26882731 X 26908464 29101336 26908464 29101336 54091539 55984067 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 10808 10808 0 Part II-B, Line 1i: Explanation of Other Lobbying Activities: Facey Medical Foundation paid membership dues to California Association of Physician Groups ("CAPG"). A portion of the dues paid are utilized by this organization for lobbying activities. 20360479 11390987 8969492 20110370 13085618 7024752 8316212 5679086 2637126 18631370 Medical Mal Practice Self-Insured Retention 6325548 6325548 179278119 175060006 4218113 -1916656 -108585 -2025241 2192872 177339344 -1916656 -1916656 179256000 22119 22119 179278119 175037887 0 175037887 22119 22119 175060006 Part X: Description of Uncertain Tax Positions Under FIN 48: FMF adopted the provisions of Financial Accounting Standards Board (FASB) Interpretation (FIN) No. 48, Accounting for Uncertainty in Income Taxes --an interpretation of FASB Statement No. 109, on October 1, 2009. As a result of the adoption, FMF did not recognize a liability for unrecognized tax contingencies. Part XI, Line 8 - Other Adjustments: Imputed interest on unihealth grant obligation : -118249. Income from K-1 adjustment: 9664. PART XII, LINE 4B: OTHER REVENUE & EXPENSE RECLASS PART XIII, LINE 4B: OTHER REVENUE & EXPENSE RECLASS 1 North East Valley Health Corp 1172 N Maclay Ave San Fernando CA 91340 237120632 501(c)(3) 26046 HEALTH CARE Providence Holy Cross Foundation 15031 Rinaldi Street Mission Hills CA 91345 954838458 501(c)(3) 10800 HEALTH CARE 2 Other Information: Part IV: Facey Medical Foundation only makes grants to 501(c)(3) organizations to ensure the funds will be used properly. X X X X 0 0 0 0 0 0 0 1 0 Guillermo Gil 285435 0 115743 0 8516 0 37323 0 0 0 447017 0 0 0 James Corwin 230860 0 62836 0 5154 0 0 0 16615 0 315465 0 0 0 Teresa David 199584 0 57253 0 5287 0 22957 0 2947 0 288028 0 0 0 Jacki Delanders 137302 0 16653 0 184 0 3353 0 4686 0 162178 0 0 0 David Day 148515 0 0 0 619 0 6500 0 7497 0 163131 0 0 0 Magaly Beilke 113436 0 21161 0 257 0 21999 0 1298 0 158151 0 0 0 Sybil Tourville 120423 0 23311 0 835 0 20500 0 2069 0 167138 0 0 0 Part I, Line 7 Facey has an administrative incentive plan ("AIP") for executive bonuses, which are determined based on financial performance, clinical performance, patient satisfaction, employee turnover, collection percentage and Facey Medical Group assessment. Financial performance is based on designated net operating income levels. The bonus incentives are based on a fixed formula, however, Facey Medical Group's board of directors assess management performance and as such has the discretion to determine a portion of the bonus. Michael Lynch Board Member 431812 Facey Eye Institute, Inc. provides billing and collection services to Facey Medical Foundation. The $431,812 consists of the gross fees received by Facey Eye Institute, Inc. from Vision Service Plan and is reimbursed to Facey Medical Foundation. The amount also includes reimbursement of overhead expenses from Facey Medical Foundation to Facey Eye Institute, Inc. in an amount that is approximately 5% of the total collections. Michael Lynch is the sole shareholder of Facey Eye Institute. All services are negotiated at market rates and are considered to be at arm's length. 0 Form 990, Part VI, Section A, line 2 Michael Lynch and Peter Richman have a business relationship. Form 990, Part VI, Section B, line 11 The 2009 Form 990 will be reviewed by the Audit Committee prior to filing. Committee Minutes will reflect the review of the tax return for the 2009 tax year. A copy of the return will be distributed to each board member and reviewed at a board meeting. The Board minutes will reflect the review of the Form 990. Form 990, Part VI, Section B, line 12c Officer and Board conduct is reviewed annually, questionnaires are filled out and sworn statements are signed stating whether or not such conflicts exist. The CEO and Board Chairperson are responsible for monitoring and enforcing compliance with the conflict of interest policies. Form 990, Part VI, Section B, line 15 All members of the FMF Administrative Team (FAM) are reviewed by the Compensation Committee which is chaired by Board Members not affiliated with Management. All salaries are compared with multiple external salary surveys and ensure no person is paid in excess of 90% of any credible survey. Form 990, Part VI, Section C, line 19 The organization makes its financial statements and tax returns available upon request. The organization does not make its governing documents or conflict of interest policy available to the public. Form 990, Schedule A, Part I, Line 3 and Schedule H: Although Facey Medical Foundation qualifies for public charity status for Schedule A purposes as an organization providing medical care pursuant to Internal Revenue Code section 170(b)(1)(A)(iii) and Treasury Regulations section 1.170A-9(d)(1)(ii), it is not required to file Schedule H with its Form 990 as it is not an organization that is required to be licensed, registered or similarly recognized by a state as a hospital. Form 990, Part VI, Section B, Line 14: While certain departments within the organization have document retention and destruction guidelines that are followed, the organization does not have a comprehensive policy for all departments that has been approved by its governing Board. Such a policy is currently being drafted for review and approval by the Board. FORM 990, PART III: The following programs and amounts represent the community benefit provided by Facey Medical Foundation and the costs associated with them for the fiscal year reported on this Form 990: Direct Charitable Write-Offs Charity (Indigent Care) $ 257,781 Medi-Medi/Medi-Cal $3,725,500 Flu Clinics $ 301,195 Community Outreach/Education Programs $1,053,071 Total Community Benefit Costs thru 9/30/10 $5,337,547 In September 2006, FMF entered into a binding grant agreement with UniHealth, whereby FMF is required to pay annual grants to UniHealth of $500,000 for a total aggregate of $5,000,000 over 10 years. In addition to the annual grant obligations, FMF may be required to make additional grant payments equal to 50% of the amount by which FMF's annual net operating income, exceeds 1.5% of FMF's annual net revenue, as defined in the grant agreement. The additional grant payments shall not exceed $5,000,000 in the aggregate for fiscal years 2006 through 2015. For the years ended September 30,2010 and 2009, respectively, no amounts have been accrued for the additional grant payments, as FMF's operating results have not met the requirements as defined in the grant agreement. The annual grant and additional grant payments, if any, are due 45 days after receipt of FMF's annual audited financial statements. As of September 30, 2010 and 2009, the $5,000,000 grant -- net of payments and a $311,000 and $429,000 discount, respectively, is reflected in net assets in the accompanying statements of financial position. The discount rate used, 4.6%, represents the 10-year treasury rate in existence at the date the grant agreement was executed. FMF may prepay the discounted amounts of any remaining grant obligation or additional grant payment at any time during the 10-year period. The grant payable as of September 30, 2010 and 2009, is $2,689,000 and $3,017,000, respectively, and is included in the accompanying statements of financial position. Because the grant was consummated with UniHealth, FMF's then sole corporate member, the transaction was considered a net asset transfer for accounting purposes. FORM 990, PART VI, LINE 16: Facey Medical Foundation has investments in limited partnerships that operate surgical centers. These limited partnerships are controlled by another tax exempt 501(c)(3) organization. FORM 990, PART VII: Total compensation reported for Gary Leary on Part VII is $64,200. The $64,200 is composed of $50,400 in legal services fees and the other $13,800 is for board service compensation.